Atos Origin Form – DWP.rtf by suchufp

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									HEALTH DECLARATION
PLEASE BRING A SIGNED COPY OF THIS FORM WITH YOU TO THE NEXT STAGE
OF THE SELECTION EXERCISE

We need to ask you about your health and your record of taking sick leave with previous
employers.

Please answer the questions in Part 1 of this form. If you cannot fit your answers in the
boxes provided, you may write on the other side of the paper.

Why we need to ask about your health and sick leave record.

The Department for Work and Pensions is an equal opportunities employer and recruits on
the basis of ability, not perceived disability.

The reasons we need to ask about your health are:

1.    If you have a disability or health condition, we need to understand how it could
      affect your ability to carry out the tasks of the job you are applying for.

2.    It enables us to consider adjustments we could make to help you take up
      employment or carry out your tasks efficiently.

3.      We must be confident that your attendance record will be good.
If you have a disability or other health condition, we will consult the company that provides
us with professional occupational health advice about workplace adjustments we might
consider making. If you have a history of ill-health, we will seek advice about whether you
are fit enough to work for us. We never decline to offer employment on health grounds
without seeking advice from an occupational health professional.

Your Consent.

Depending on the information you provide, our occupational health advisers, Atos
Healthcare, may need to speak to you or consult your GP before giving us advice. They
will do this to ensure that the advice they provide is based on all the facts.

By completing Part 2 of this form you will provide consent for Atos Healthcare to contact
you, or your GP, if they need to.

Confidentiality

The information you provide on this form will be treated in the strictest confidence and will
be seen by one of our Personnel Managers only if you are recommended for appointment.

If you want the details of a health condition to be known only by a medical professional,
you may give this form back to us in a sealed envelope. We will pass this on to Atos
Healthcare unopened.

Failure to Provide Information

You employment could be terminated if it subsequently comes to light that the information
you provided was inaccurate or incomplete.
                                                                 DWP Consent Form V2 10/06/2010
HEALTH DECLARATION – PART 1

Your Name:

Your date of birth:

Details of the post
applied for:



Question 1:           Do you have a disability?

                      Please answer yes or no. If yes, please explain.

Your answer:




Question 2:           Do you have any other health condition?

                      Please answer yes or no. If yes, please explain.

Your answer:




Question 3:           Are you on a waiting list to see a specialist as an outpatient, or
                      have you seen one in the last six months?

                      Please answer yes or no. If yes, please explain.

Your answer:




                                                            DWP Consent Form V2 10/06/2010
Question 4:              Are you on a waiting list for an operation?

                         Please answer yes or no. If yes, please explain.
Your answer:




Question 5:              Have you ever had a medical condition that was or may have
                         been caused by work factors?

                         Please answer yes or no. If yes, please explain what the
                         condition was and say whether you are in receipt of Industrial
                         Injuries Benefit.

Your answer:




Question 6:              Do you have difficulty with any of the following that interfere
                         substantially with normal day to day activities?

                         Please tick yes or no.

                                                                           Yes       No 
Walking or mobility
Vision (apart from needing glasses or contact lenses for correction)
Ability to learn or understand things
Ability to read
Hearing
Speech
Ability to lift, carry or move everyday objects
Memory
Concentration
Physical co-ordination
Continence
Manual dexterity
Perception of risk or physical danger


                                                                DWP Consent Form V2 10/06/2010
Question 7:    Do you have any need for specific arrangements to assist in
               the performance of any aspects of your job?

               Please explain what these arrangements are. If any of your
               previous employers adjusted your working environment or
               terms of employment to assist you in relation to a disability or
               health condition, please tell us about it.

Your answer:




Question 8:    Have you ever been refused employment on health grounds?

               Please answer yes or no. If yes, please explain.

Your answer:




Question 9:    Have you ever left, been dismissed or retired from
               employment for health reasons?

               Please answer yes or no. If yes, please explain.

Your answer:




                                                    DWP Consent Form V2 10/06/2010
Question 10:   How many days absence from work did you have off in the last
               12 months with your most recent employer(s)? What was this
               for?

               Please provide the number of days and an explanation.

Your answer:




Question 11:   Are you aware of any medical problems that may affect your
               ability to work regularly or effectively that you have not
               already told us about?

               Please answer yes or no. If yes, please explain.

Your answer:




Question 12:   Our occupational health advisers will contact you if they need
               to talk to you face to face or by telephone about your answers.

               Please tell us if you need them to make special arrangements
               for this (e.g. if you have mobility problems).

Your answer:




                                                    DWP Consent Form V2 10/06/2010
Signed       Date

Print Name




                    DWP Consent Form V2 10/06/2010
      HEALTH DECLARATION – PART 2

                                    Atos Healthcare Consent Form
We need to ask our Occupational Health providers Atos Healthcare to provide advice regarding your current
health / well being in relation to your potential employment. To do this we require your informed consent. Please
complete each section of this form, then sign and date. Thank you.
 Part A: Personal Details – Please complete all details
 Surname:

 Forename (s):

 Title:           Mr         Mrs          Miss         Ms           Other        Date of Birth

 Home Address
 Town:
 County:
 Post code:

 Contact Telephone Number



 Part B: Consent Declaration
 By signing below I confirm that I consent to my employer referring me to Occupational Health and
 understand the reasons for the referral. Following confidential health assessment I understand that a report
 will be sent to my employer with regard to my fitness for employment / or my fitness to carry out the duties
 of my role both now and in the future. I agree to such a report being sent to my employer. As part of the
 referral I understand that the health assessment will be undertaken either by telephone, face to face or by
 file opinion. I understand that the content of the report will be discussed with me at the end of the
 consultation, when this has taken place. A file opinion relating to fitness will only be provided where a
 health assessment has been undertaken by paper screening and no health issues have been identified.

 Please answer each question by ticking yes / no

 I agree to my General Practitioner, and if necessary the Specialist I am attending,    Yes          No
 giving information about my medical condition, if requested by Atos Healthcare.
 (In respect of requests for further medical evidence questions will only be asked
 that relate to the reason the consent was provided).




                                                                                  DWP Consent Form V2 10/06/2010
                                      Access to Medical Reports Act 1988
Under the terms of the above act you have the right to withhold your consent to Atos Healthcare to apply to
your general practitioner / hospital specialist for medical information.
If you give your consent you have the right to see the information in the report before it is sent to Atos
Healthcare.
You have 21 days from the date of the Atos Healthcare letter notifying you that a report has been requested,
in which to ask your general practitioner / hospital specialist to let you see the report. They will tell you if
you cannot see any part of the report for professional medical reasons. If you are given access to the report
your General Practitioner / Specialist will not send it to Atos Healthcare until you give your consent.
If you regard any information in the report as incorrect or misleading you can ask, in writing, for it to be
amended. (Please note, if your General Practitioner or Specialist does not accept that the information is
incorrect or misleading, they are not required to make any amendment, but in these cases they will invite
you to prepare a written statement on the disputed information, which will be attached to the report when it
is sent to Atos Healthcare).
Subject to the provision of the Act, you have the right to see information about your medical condition for
up to six months after it has been sent to Atos Healthcare. If your General Practitioner /Specialist gives you
a copy of the report, they may charge you a reasonable fee to cover the cost of supplying it.

I wish to see any such report before it is sent to Atos Healthcare.                    Yes   No
I agree that relevant medical notes can be submitted, in confidence, to the agents for Yes   No
the CSPS.
                                             Data Protection Act 1998
Access to Medical Reports Act 1988 does not affect an individual’s right to make an access request in
relation to their personal data in accordance with the DPA 1998.


Part C: General Practitioner’s Details
Surname:

Title:                        Mr           Mrs        Miss            Ms          Dr                  Initials
Address:
Town:
County:
Post Code:


Telephone:



Part D: Other Specialist's Details, if applicable
Surname:

Title:                        Mr         Mrs        Miss         Ms          Dr                 Initials
Speciality:
Address:
Town:
County:
Post Code:

Hospital Unit No.
Telephone:




Signed:                                                                                 Date:

Print Name:




                                                                                   DWP Consent Form V2 10/06/2010

								
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